Gracilis tendon harvesting using the posterior approach for anatomical ankle ligament reconstruction: a rapid and reliable technique with minimal neurological complications

Gracilis tendon harvesting using the posterior approach for anatomical ankle ligament reconstruction: a rapid and reliable technique with minimal neurological complications | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Gracilis tendon harvesting using the posterior approach for anatomical ankle ligament reconstruction: a rapid and reliable technique with minimal neurological complications Maria Khvesyuk, . ReSurg, Alexis Nogier, Philippe Beaudet This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7997508/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Graft harvesting is an important step when performing ligament reconstruction. The anterior approach is a well-described technique for hamstring tendon harvesting as it is commonly used for anterior cruciate ligament reconstruction, as an anterior incision is required to drill the tunnel. However, in case of gracilis harvesting for ankle ligament reconstruction, an anterior approach could lead to unnecessary complications and donor-site morbidity, and therefore the posterior approach is preferred, as it decreases complications and morbidity. Purpose To report donor site morbidity following gracilis harvesting using a posterior approach for anatomic ankle ligament reconstruction. Methods Between January 2023 and March 2025, 33 patients underwent anatomic ankle ligament reconstruction with a gracilis autograft for chronic ankle instability. In 2 patients, it was not possible to harvest the gracilis due to obesity, leaving 31 patients for assessment. The gracilis was harvested in flexion or extension position, based on the BMI of the patient. The authors noted graft length, diameter, time to harvest the gracilis, and whether patients had any neuropathy of the saphenous nerve or discomfort around the donor-site. Results The remaining 31 patients comprised 12 males, and 19 females, were aged 36.8 ± 12.6 (range, 17–60) with a BMI of 27.1 ± 4.4 (range, 18–37). Of the 31 patients, the gracilis was harvest with the knee flexed in 30 (97%), and knee extended in 1 (3%). The length of the graft was 18.9 ± 2.9 cm, and was cut to 13.8 ± 0.6 cm, with a diameter proximally of 3.7 ± 0.4mm and distally of 3.9 ± 0.5mm. The time to harvest the graft was 6.6 ± 4.3 minutes. At a follow-up of 5.1 ± 3.8 months, 1 patient reported neuropathy of the saphenous nerve, and 5 reported discomfort around the donor-site, which resolved in 3. Conclusion Gracilis harvesting using the posterior approach is a safe technique with minimal complications and donor-site morbidity. Graft harvesting Gracilis posterior approach Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Gracilis tendon harvesting conventionally involves an anteromedial approach on the proximal tibia at the level of the pes anserinus, which is used by the majority of surgeons. This surgical approach has been associated with complications, including injury to the infrapatellar branches of the saphenous nerve, premature graft amputation, and unintentional gracilis harvesting when only the semitendinosus tendon is required [ 1 – 4 ]. Prodromos et al.[ 5 ] recommended a primary posterior approach to guide harvesting via a reduced anterior approach, avoiding risk of premature sectioning due to adherence.The technique has undergone several modifications to reduce complications and improve postoperative outcomes [ 6 , 5 , 7 – 9 ]. This approach was believed to simplify the identification of hamstring tendons, reduce saphenous nerve injury, and prevent premature amputation of the tendons [ 5 ]. Several studies have been published regarding the posterior approach to harvest the graft followed by anterior cruciate ligament reconstruction. However, in the case of graft harvesting for ankle ligament reconstruction, it is even more important to minimize donor-site morbidity at the knee. The principal objective of the present study was to report the clinical outcomes of harvesting the gracilis tendon using the posterior approach, especially terms of nerve injury, . Methods Between January 2023 and March 2025, 33 patients underwent anatomic ankle ligament reconstruction for chronic ankle instability using a gracilis autograft harvested through the posterior approach. The gracilis was harvested in flexion or extension position, based on the BMI of the patient. All patients provided informed consent, and study was approved by a local ethics committee (E2026-12). Preoperative assessment All patients underwent standard ankle assessment (clinical examination, X-ray, MRI). Patients were assessed whether they underwent previous knee surgery with hamstring graft harvesting. Surgical technique The patient is positioned with the lower limb in external hip rotation and knee flexion (Figs. 1 and 2). The surgeon positions themselves on the medial side of the knee. The tendons in the popliteal fossa are located by rotating the foot externally to stretch the structures. A transverse incision of a few centimetres centered on the tendons is made, if possible in a flexion crease, which will be enlarged if necessary. The subcutaneous tissue is dissected and then the tendon fascia is opened using Metzenbaum scissors or a dissector. The semitendinosus tendon can be identified as the largest and most lateral tendon, while the gracilis tendon is more medial and superficial. The tendon is isolated and pulled outside. To facilitate this, knee flexion can be increased (Fig. 3). The gracilis tendon is harvested in retrograde using a closable stripper. The stripper is oriented towards the proximal insertion of the tendon in the direction of the pubis (Fig. 4). The graft is extracted at the incision site, and the distal stump is left in place (Fig. 5). The muscle fibres are removed using Mayo scissors. The harvested tendon is measured and cut to 14 cm to form the graft. Then the skin is closed with absorbable sutures. The graft is then prepared by a non-absorbable running suture of both ends over 1 cm. The surgeon then continues with the arthroscopic procedure of reconstructing the ankle ligaments. Postoperative rehabilitation Patients are required to use a walking boot for 3–4 weeks, and are allowed weight-bearing. Physiotherapy is started after this period. Intra- and post-operative assessment Intraoperatively, the authors noted graft length, diameter and recorded the time to harvest the gracilis. At a follow-up of minimum 4 weeks following the surgery, an observer assessed the joint range of motion and stability with examination for laxity using external manoeuvres. Furthermore, sensory-motor deficits are examined, and whether patients had any neuropathy of the saphenous nerve or discomfort on a numeric rating scale (0, no discomfort; 10, maximum discomfort) around the donor-site. In case of no saphenous nerve injury or discomfort, no further follow-ups were required. Statistical analysis Due to the small cohort size, only descriptive statistics were used to summarise the data. No sample size calculation was performed, as all patients registered were enrolled. Results Of the 33 patients, it was not possible to harvest the gracilis through the posterior approach due to obesity in 2 patients, leaving 31 patients for assessment (Table 1). The remaining 31 patients comprised 12 males, and 19 females, were aged 36.8 ± 12.6 (range, 17–60) with a BMI of 27.1 ± 4.4 (range, 18–37). Of the 31 patients, the gracilis was harvested with the knee flexed in 30 (97%), and knee extended in 1 (3%). Table 1: Patient characteristics of the initial and final cohort Initial cohort (n = 33) Final cohort (n = 31) Mean ± SD Range Mean ± SD Range n % n % Age 36.5 ± 12.3 17 – 60 36.8 ± 12.6 17 – 60 Weight (kg) 78.3 ± 17.2 54.0 – 138.0 77.4 ± 17.3 54.0 – 138.0 Height (cm) 1.68 ± 0.1 1.55 – 1.93 1.68 ± 0.09 1.55 – 1.93 BMI 27.5 ± 4.6 18.5 – 37.0 27.1 ± 4.4 18.5 – 37.0 Female 21 58% 19 61% Abbreviations: BMI, Body Mass Index; cm, centimeter; kg, kilogram; SD, Standard Deviation The length of the graft was 18.9 ± 2.9cm, and was cut to 13.8 ± 0.6cm, with a diameter proximally of 3.7 ± 0.4mm and distally of 3.9 ± 0.5mm (Table 2). The time to harvest the graft was 6.6 ± 4.3 minutes (range, 2 to 25). At a follow-up of 5.1 ± 3.7 months, 5 reported discomfort around the donor-site, which resolved in 3 (Table 3). One patient reported neuropathy of the saphenous nerve, as this patient was obese (BMI, 32.7) it took 25 minutes to identify the anatomic structures. Table 2: Intraoperative characteristics Final cohort (n = 31) Mean ± SD Range n % Harvested graft length 18.9 ± 2.9 12 – 24 Graft length after sectioning 13.8 ± 0.6 12 – 15 Diameter graft proximal 3.7 ± 0.43 3 – 5 Diameter graft distal 3.9 ± 0.5 3 – 5 Graft harvesting time (min) 6.6 ± 4.3 2 – 25 Overall surgery time (min) 59.2 ± 12.0 39 – 89 Abbreviations: BMI, Body Mass Index; cm, centimeter; kg, kilogram; SD, Standard Deviation Table 3: Postoperative characteristics Final cohort (n = 31) Mean ± SD Range n % Follow-up time (months) 5.1 ± 3.7 1 – 18 Saphenous nerve injury 1 3% Donor-site discomfort 5 16% Abbreviations: BMI, Body Mass Index; cm, centimeter; kg, kilogram; SD, Standard Deviation Discussion The most important findings of this study were that, harvesting the gracilis tendon through the posterior approach is a safe and effective technique, with minimal donor-site morbidity. In a recent systematic review by Thamrongskulsiri et al.[ 10 ], the authors found that anteromedial approaches for hamstring harvest had higher rates of saphenous nerve injury and longer operative times compared to posteromedial approaches. The anteromedial approach also resulted in a longer semitendinosus graft length. Furthermore, Thamrongskulsiri et al.[ 10 ] found that the posteromedial harvest group reported higher cosmetic satisfaction than the anteromedial harvest group, though overall satisfaction levels were similar between the groups. It is worth noting that Thamrongskulsiri et al.[ 10 ] investigated graft harvesting for anterior cruciate ligament repair, which might lead to different outcomes compared to graft harvesting for ankle ligament reconstruction. Harvesting through the posterior approach has several benefits; Roussignol et al.[ 9 ] found that the tendon can be havested through an incision with a mean length of 26.5 mm, which could be further reduced in case of good tendon palpation. Furthermore, posterior gracilis tendon harvesting leads to less saphenous nerve lesions. In a study by Mochizuki et al.[ 11 ], the authors reported a 58% rate of postoperative hypoesthesia in a series of 103 patients following anterior graft harvesting, and Sanders et al.[ 12 ] reported a 74% rate. Furthermore, when nerve lesions occur, they are usually chronic. In the present study, there were minimal nerve lesions as only 1 patient reported neuropathy of the saphenous nerve, and 5 reported discomfort around the donor-site, which resolved in 3. Finally, the authors recommend harvesting the tendon with the knee in flexion and the hip in external rotation, which relaxes the saphenous nerve. In the authors’ experience, the graft length is shorter using the posterior approach, because it is cut more proximally, but it is still sufficiently long to perform the reconstruction. Furthermore, more experience is required as harvesting is more difficult and time-consuming, but it is commonly performed for anterior cruciate ligament repair. It provides a more aesthetic outcome, especially as this procedure is often performed in young athletic patients, as the scar is hidden in the popliteal fossa using the posterior approach. This approach is unfortunately not possible in obese patients, as it is more difficult to use the posterior approach, and therefore the anterior approach is preferred. Limitations The results of this study should be interpreted with the following limitations in mind. First, these are only the results of a small case series. Comparative studies could provide more information on the differences in rates of nerve injury and donor-site morbidity. Second, due to the small cohort size it was not possible to perform uni- and/or multivariable analysis to determine which patient characteristics influence the outcome. Third, no clinical scores of the ankle were collected, as this was not the aim of the study. Conclusion Gracilis harvesting using the posterior approach is a safe technique with minimal complications and donor-site morbidity, but is not preferred in patients with obesity. Declarations Ethics approval and consent to participate All patients provided informed consent, and study was approved by a local ethics committee (Comité d'Ethique pour la Recherche sur Données Existantes et/ou hors loi Jardé CHU de Rouen; E2026-12). The study adhered to the rules outlined in the Declaration of Helsinki. Consent for publication Not applicable Competing interests The authors declare that they have no competing interests. Funding The authors are grateful to Clinique Trenel for funding the statistical analysis and manuscript preparation for this study. Author Contribution PB Conceptualization, Project administration, Interpretation of findings, Writing, ValidationMK Data collection, Interpretation of findings, ValidationFVR Project administration; Data analysis, Statistics, Visualisation, Interpretation of findings; Writing, ValidationMS Interpretation of findings, ValidationAN Funding, Validation Acknowledgements Not applicable Data Availability The datasets used and analysed during the current study are available from the corresponding author on reasonable request. References de Padua VB, Nascimento PE, Silva SC, de Gusmão Canuto SM, Zuppi GN, de Carvalho SM (2015) Saphenous nerve injury during harvesting of one or two hamstring tendons for anterior cruciate ligament reconstruction. Rev Bras Ortop 50 (5):546-549. doi:10.1016/j.rboe.2015.08.007 Ochiai S, Hagino T, Senga S, Yamashita T, Oda K, Haro H (2017) Injury to infrapatellar branch of saphenous nerve in anterior cruciate ligament reconstruction using vertical skin incision for hamstring harvesting: risk factors and the influence of treatment outcome. J Orthop Surg Res 12 (1):101. doi:10.1186/s13018-017-0596-x Ruffilli A, De Fine M, Traina F, Pilla F, Fenga D, Faldini C (2017) Saphenous nerve injury during hamstring tendons harvest: Does the incision matter? A systematic review. Knee Surg Sports Traumatol Arthrosc 25 (10):3140-3145. doi:10.1007/s00167-016-4217-8 Charalambous CP, Kwaees TA (2012) Anatomical considerations in hamstring tendon harvesting for anterior cruciate ligament reconstruction. Muscles Ligaments Tendons J 2 (4):253-257 Prodromos CC, Han YS, Keller BL, Bolyard RJ (2005) Posterior mini-incision technique for hamstring anterior cruciate ligament reconstruction graft harvest. Arthroscopy 21 (2):130-137. doi:10.1016/j.arthro.2004.09.010 Kodkani PS, Govekar DP, Patankar HS (2004) A new technique of graft harvest for anterior cruciate ligament reconstruction with quadruple semitendinosus tendon autograft. Arthroscopy 20 (8):e101-104. doi:10.1016/j.arthro.2004.07.016 Wilson TJ, Lubowitz JH (2013) Minimally invasive posterior hamstring harvest. Arthrosc Tech 2 (3):e299-301. doi:10.1016/j.eats.2013.04.008 Letartre R, Isida R, Pommepuy T, Miletic B (2014) Horizontal posterior hamstring harvest. Orthop Traumatol Surg Res 100 (8):959-961. doi:10.1016/j.otsr.2014.08.002 Roussignol X, Bertiaux S, Rahali S, Potage D, Duparc F, Dujardin F (2015) Minimally invasive posterior approach in the popliteal fossa for semitendinosus and gracilis tendon harvesting: an anatomic study. Orthop Traumatol Surg Res 101 (2):167-172. doi:10.1016/j.otsr.2014.12.009 Thamrongskulsiri N, Limskul D, Tanpowpong T, Kuptniratsaikul S, Itthipanichpong T (2024) The Posteromedial Approach for Harvesting Hamstring Autografts Results in Fewer Incidents of Saphenous Nerve Injury Compared to the Conventional Anteromedial Approach: A Systematic Review and Meta-Analysis. Clin Orthop Surg 16 (4):559-569. doi:10.4055/cios23396 Mochizuki T, Akita K, Muneta T, Sato T (2003) Anatomical bases for minimizing sensory disturbance after arthroscopically-assisted anterior cruciate ligament reconstruction using medial hamstring tendons. Surg Radiol Anat 25 (3-4):192-199. doi:10.1007/s00276-003-0130-1 Sanders B, Rolf R, McClelland W, Xerogeanes J (2007) Prevalence of Saphenous Nerve Injury After Autogenous Hamstring Harvest: An Anatomic and Clinical Study of Sartorial Branch Injury. Arthroscopy: The Journal of Arthroscopic & Related Surgery 23 (9):956-963. doi:10.1016/j.arthro.2007.03.099 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7997508","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":625814079,"identity":"c6395f15-6d08-4302-9678-7017c1d9fef7","order_by":0,"name":"Maria Khvesyuk","email":"","orcid":"","institution":"Clinique Trénel","correspondingAuthor":false,"prefix":"","firstName":"Maria","middleName":"","lastName":"Khvesyuk","suffix":""},{"id":625814081,"identity":"6dd22709-1d4d-479e-ab19-280f1476a626","order_by":1,"name":". ReSurg","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAuklEQVRIiWNgGAWjYBAC9nYgkcBgQ4IWnsNgLWmkamFgOEyKFmbmYx8e/Dmfz89/xuzjFwY7Od0GglrYkmcktt22nDkjx3i2DEOysdkBAlrsmXmMGRIbbhsY3OAxZpZgOJC4jZAWHpCWhD/nDOzPnyFJC9sBAwOGHGPGD8RpYUtmSGxLNpC4kVbMzGBAhF942JsPM/74Y2fA3394M+OPCjs5glpQADOPASnKQYDxB6k6RsEoGAWjYEQAAMHIN23XqkVGAAAAAElFTkSuQmCC","orcid":"","institution":"Resurg (Switzerland)","correspondingAuthor":true,"prefix":"","firstName":".","middleName":"","lastName":"ReSurg","suffix":""},{"id":625814084,"identity":"e6d67a4b-9ffa-4903-9686-e7381d8b9be5","order_by":2,"name":"Alexis Nogier","email":"","orcid":"","institution":"Clinique Trénel","correspondingAuthor":false,"prefix":"","firstName":"Alexis","middleName":"","lastName":"Nogier","suffix":""},{"id":625814086,"identity":"b3582b11-68a8-4c21-90c1-45615d58375d","order_by":3,"name":"Philippe Beaudet","email":"","orcid":"","institution":"Clinique Trénel","correspondingAuthor":false,"prefix":"","firstName":"Philippe","middleName":"","lastName":"Beaudet","suffix":""}],"badges":[],"createdAt":"2025-10-31 10:38:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7997508/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7997508/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107617254,"identity":"03b58eae-0767-42dd-8d25-5494ece3a414","added_by":"auto","created_at":"2026-04-23 09:17:53","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":5499834,"visible":true,"origin":"","legend":"\u003cp\u003eLocation for incision for graft harvesting\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7997508/v1/226754b39086a86017f7a088.jpg"},{"id":107617256,"identity":"429fe0da-a262-4d94-b031-545a746e181e","added_by":"auto","created_at":"2026-04-23 09:17:54","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":252948,"visible":true,"origin":"","legend":"\u003cp\u003ePatient postioning\u003c/p\u003e","description":"","filename":"Figure2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7997508/v1/55829071bccefdf474f7f5c2.jpeg"},{"id":107617257,"identity":"9e905b88-fafb-44c9-a050-253233fd0e4a","added_by":"auto","created_at":"2026-04-23 09:17:54","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":472355,"visible":true,"origin":"","legend":"\u003cp\u003ePulling out the gracilis tendon\u003c/p\u003e","description":"","filename":"Figure3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7997508/v1/3cc774a42264a60a9fc0ba1f.jpeg"},{"id":107707334,"identity":"4aeab962-7bee-4c65-85b1-37c39443ab0a","added_by":"auto","created_at":"2026-04-24 09:20:06","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":311943,"visible":true,"origin":"","legend":"\u003cp\u003eThe tendon is isolated and pulled outside. To facilitate this, knee flexion can be increased\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7997508/v1/0eaaa1f67c1cca9cf892bb46.jpg"},{"id":107617255,"identity":"2c994f79-55d8-4e36-8617-1d65a93ab53c","added_by":"auto","created_at":"2026-04-23 09:17:54","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":267037,"visible":true,"origin":"","legend":"\u003cp\u003eThe gracilis tendon is harvested in retrograde using a closable stripper\u003c/p\u003e","description":"","filename":"Figure5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7997508/v1/8bac27bd24f3bbe9b21732ef.jpg"},{"id":108345624,"identity":"bb7d7267-bad0-4607-8e86-2e05fb866a95","added_by":"auto","created_at":"2026-05-03 07:41:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":7089583,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7997508/v1/9959dd1c-0f01-4b91-923c-c43f381563cd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Gracilis tendon harvesting using the posterior approach for anatomical ankle ligament reconstruction: a rapid and reliable technique with minimal neurological complications","fulltext":[{"header":"Background","content":"\u003cp\u003eGracilis tendon harvesting conventionally involves an anteromedial approach on the proximal tibia at the level of the pes anserinus, which is used by the majority of surgeons. This surgical approach has been associated with complications, including injury to the infrapatellar branches of the saphenous nerve, premature graft amputation, and unintentional gracilis harvesting when only the semitendinosus tendon is required [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eProdromos et al.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] recommended a primary posterior approach to guide harvesting via a reduced anterior approach, avoiding risk of premature sectioning due to adherence.The technique has undergone several modifications to reduce complications and improve postoperative outcomes [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This approach was believed to simplify the identification of hamstring tendons, reduce saphenous nerve injury, and prevent premature amputation of the tendons [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Several studies have been published regarding the posterior approach to harvest the graft followed by anterior cruciate ligament reconstruction. However, in the case of graft harvesting for ankle ligament reconstruction, it is even more important to minimize donor-site morbidity at the knee.\u003c/p\u003e \u003cp\u003eThe principal objective of the present study was to report the clinical outcomes of harvesting the gracilis tendon using the posterior approach, especially terms of nerve injury, .\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eBetween January 2023 and March 2025, 33 patients underwent anatomic ankle ligament reconstruction for chronic ankle instability using a gracilis autograft harvested through the posterior approach. The gracilis was harvested in flexion or extension position, based on the BMI of the patient. All patients provided informed consent, and study was approved by a local ethics committee (E2026-12).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePreoperative assessment\u003c/h2\u003e \u003cp\u003eAll patients underwent standard ankle assessment (clinical examination, X-ray, MRI). Patients were assessed whether they underwent previous knee surgery with hamstring graft harvesting.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurgical technique\u003c/h3\u003e\n\u003cp\u003eThe patient is positioned with the lower limb in external hip rotation and knee flexion (Figs.\u0026nbsp;1 and 2). The surgeon positions themselves on the medial side of the knee. The tendons in the popliteal fossa are located by rotating the foot externally to stretch the structures. A transverse incision of a few centimetres centered on the tendons is made, if possible in a flexion crease, which will be enlarged if necessary. The subcutaneous tissue is dissected and then the tendon fascia is opened using Metzenbaum scissors or a dissector.\u003c/p\u003e \u003cp\u003eThe semitendinosus tendon can be identified as the largest and most lateral tendon, while the gracilis tendon is more medial and superficial. The tendon is isolated and pulled outside. To facilitate this, knee flexion can be increased (Fig.\u0026nbsp;3).\u003c/p\u003e \u003cp\u003eThe gracilis tendon is harvested in retrograde using a closable stripper. The stripper is oriented towards the proximal insertion of the tendon in the direction of the pubis (Fig.\u0026nbsp;4). The graft is extracted at the incision site, and the distal stump is left in place (Fig.\u0026nbsp;5). The muscle fibres are removed using Mayo scissors. The harvested tendon is measured and cut to 14 cm to form the graft. Then the skin is closed with absorbable sutures.\u003c/p\u003e \u003cp\u003eThe graft is then prepared by a non-absorbable running suture of both ends over 1 cm. The surgeon then continues with the arthroscopic procedure of reconstructing the ankle ligaments.\u003c/p\u003e\n\u003ch3\u003ePostoperative rehabilitation\u003c/h3\u003e\n\u003cp\u003ePatients are required to use a walking boot for 3\u0026ndash;4 weeks, and are allowed weight-bearing. Physiotherapy is started after this period.\u003c/p\u003e\n\u003ch3\u003eIntra- and post-operative assessment\u003c/h3\u003e\n\u003cp\u003eIntraoperatively, the authors noted graft length, diameter and recorded the time to harvest the gracilis. At a follow-up of minimum 4 weeks following the surgery, an observer assessed the joint range of motion and stability with examination for laxity using external manoeuvres. Furthermore, sensory-motor deficits are examined, and whether patients had any neuropathy of the saphenous nerve or discomfort on a numeric rating scale (0, no discomfort; 10, maximum discomfort) around the donor-site. In case of no saphenous nerve injury or discomfort, no further follow-ups were required.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eDue to the small cohort size, only descriptive statistics were used to summarise the data. No sample size calculation was performed, as all patients registered were enrolled.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOf the 33 patients, it was not possible to harvest the gracilis through the posterior approach due to obesity in 2 patients, leaving 31 patients for assessment (Table\u0026nbsp;1). The remaining 31 patients comprised 12 males, and 19 females, were aged 36.8\u0026thinsp;\u0026plusmn;\u0026thinsp;12.6 (range, 17\u0026ndash;60) with a BMI of 27.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4 (range, 18\u0026ndash;37). Of the 31 patients, the gracilis was harvested with the knee flexed in 30 (97%), and knee extended in 1 (3%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"15\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"13\" nameend=\"c13\" namest=\"c1\"\u003e \u003cp\u003eTable\u0026nbsp;1: Patient characteristics of the initial and final cohort\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c8\" namest=\"c3\"\u003e \u003cp\u003eInitial cohort (n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c15\" namest=\"c10\"\u003e \u003cp\u003eFinal cohort (n\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e36.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e12.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eWeight (kg)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e54.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e138.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e77.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e17.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e54.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e138.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eHeight (cm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e1.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e1.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBMI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e37.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e27.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e4.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e18.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e37.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e58%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e61%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"15\"\u003e\u003cem\u003eAbbreviations: BMI, Body Mass Index; cm, centimeter; kg, kilogram; SD, Standard Deviation\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe length of the graft was 18.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9cm, and was cut to 13.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6cm, with a diameter proximally of 3.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4mm and distally of 3.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5mm (Table\u0026nbsp;2). The time to harvest the graft was 6.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3 minutes (range, 2 to 25). At a follow-up of 5.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7 months, 5 reported discomfort around the donor-site, which resolved in 3 (Table\u0026nbsp;3). One patient reported neuropathy of the saphenous nerve, as this patient was obese (BMI, 32.7) it took 25 minutes to identify the anatomic structures.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eTable\u0026nbsp;2: Intraoperative characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"7\" nameend=\"c9\" namest=\"c3\"\u003e \u003cp\u003eFinal cohort (n\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eHarvested graft length\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eGraft length after sectioning\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDiameter graft proximal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDiameter graft distal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eGraft harvesting time (min)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eOverall surgery time (min)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003e\u003cem\u003eAbbreviations: BMI, Body Mass Index; cm, centimeter; kg, kilogram; SD, Standard Deviation\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabc\" border=\"1\"\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eTable\u0026nbsp;3: Postoperative characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c8\" namest=\"c3\"\u003e \u003cp\u003eFinal cohort (n\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFollow-up time (months)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSaphenous nerve injury\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDonor-site discomfort\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u003cem\u003eAbbreviations: BMI, Body Mass Index; cm, centimeter; kg, kilogram; SD, Standard Deviation\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe most important findings of this study were that, harvesting the gracilis tendon through the posterior approach is a safe and effective technique, with minimal donor-site morbidity. In a recent systematic review by Thamrongskulsiri et al.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], the authors found that anteromedial approaches for hamstring harvest had higher rates of saphenous nerve injury and longer operative times compared to posteromedial approaches. The anteromedial approach also resulted in a longer semitendinosus graft length. Furthermore, Thamrongskulsiri et al.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] found that the posteromedial harvest group reported higher cosmetic satisfaction than the anteromedial harvest group, though overall satisfaction levels were similar between the groups. It is worth noting that Thamrongskulsiri et al.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] investigated graft harvesting for anterior cruciate ligament repair, which might lead to different outcomes compared to graft harvesting for ankle ligament reconstruction.\u003c/p\u003e \u003cp\u003eHarvesting through the posterior approach has several benefits; Roussignol et al.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] found that the tendon can be havested through an incision with a mean length of 26.5 mm, which could be further reduced in case of good tendon palpation. Furthermore, posterior gracilis tendon harvesting leads to less saphenous nerve lesions. In a study by Mochizuki et al.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], the authors reported a 58% rate of postoperative hypoesthesia in a series of 103 patients following anterior graft harvesting, and Sanders et al.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] reported a 74% rate. Furthermore, when nerve lesions occur, they are usually chronic. In the present study, there were minimal nerve lesions as only 1 patient reported neuropathy of the saphenous nerve, and 5 reported discomfort around the donor-site, which resolved in 3. Finally, the authors recommend harvesting the tendon with the knee in flexion and the hip in external rotation, which relaxes the saphenous nerve.\u003c/p\u003e \u003cp\u003eIn the authors\u0026rsquo; experience, the graft length is shorter using the posterior approach, because it is cut more proximally, but it is still sufficiently long to perform the reconstruction. Furthermore, more experience is required as harvesting is more difficult and time-consuming, but it is commonly performed for anterior cruciate ligament repair. It provides a more aesthetic outcome, especially as this procedure is often performed in young athletic patients, as the scar is hidden in the popliteal fossa using the posterior approach. This approach is unfortunately not possible in obese patients, as it is more difficult to use the posterior approach, and therefore the anterior approach is preferred.\u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003eThe results of this study should be interpreted with the following limitations in mind. First, these are only the results of a small case series. Comparative studies could provide more information on the differences in rates of nerve injury and donor-site morbidity. Second, due to the small cohort size it was not possible to perform uni- and/or multivariable analysis to determine which patient characteristics influence the outcome. Third, no clinical scores of the ankle were collected, as this was not the aim of the study.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eGracilis harvesting using the posterior approach is a safe technique with minimal complications and donor-site morbidity, but is not preferred in patients with obesity.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eAll patients provided informed consent, and study was approved by a local ethics committee (Comit\u0026eacute; d'Ethique pour la Recherche sur Donn\u0026eacute;es Existantes et/ou hors loi Jard\u0026eacute; CHU de Rouen; E2026-12). The study adhered to the rules outlined in the Declaration of Helsinki.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe authors are grateful to Clinique Trenel for funding the statistical analysis and manuscript preparation for this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003ePB Conceptualization, Project administration, Interpretation of findings, Writing, ValidationMK Data collection, Interpretation of findings, ValidationFVR Project administration; Data analysis, Statistics, Visualisation, Interpretation of findings; Writing, ValidationMS Interpretation of findings, ValidationAN Funding, Validation\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eNot applicable\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ede Padua VB, Nascimento PE, Silva SC, de Gusm\u0026atilde;o Canuto SM, Zuppi GN, de Carvalho SM (2015) Saphenous nerve injury during harvesting of one or two hamstring tendons for anterior cruciate ligament reconstruction. Rev Bras Ortop 50 (5):546-549. doi:10.1016/j.rboe.2015.08.007\u003c/li\u003e\n\u003cli\u003eOchiai S, Hagino T, Senga S, Yamashita T, Oda K, Haro H (2017) Injury to infrapatellar branch of saphenous nerve in anterior cruciate ligament reconstruction using vertical skin incision for hamstring harvesting: risk factors and the influence of treatment outcome. J Orthop Surg Res 12 (1):101. doi:10.1186/s13018-017-0596-x\u003c/li\u003e\n\u003cli\u003eRuffilli A, De Fine M, Traina F, Pilla F, Fenga D, Faldini C (2017) Saphenous nerve injury during hamstring tendons harvest: Does the incision matter? A systematic review. Knee Surg Sports Traumatol Arthrosc 25 (10):3140-3145. doi:10.1007/s00167-016-4217-8\u003c/li\u003e\n\u003cli\u003eCharalambous CP, Kwaees TA (2012) Anatomical considerations in hamstring tendon harvesting for anterior cruciate ligament reconstruction. Muscles Ligaments Tendons J 2 (4):253-257\u003c/li\u003e\n\u003cli\u003eProdromos CC, Han YS, Keller BL, Bolyard RJ (2005) Posterior mini-incision technique for hamstring anterior cruciate ligament reconstruction graft harvest. Arthroscopy 21 (2):130-137. doi:10.1016/j.arthro.2004.09.010\u003c/li\u003e\n\u003cli\u003eKodkani PS, Govekar DP, Patankar HS (2004) A new technique of graft harvest for anterior cruciate ligament reconstruction with quadruple semitendinosus tendon autograft. Arthroscopy 20 (8):e101-104. doi:10.1016/j.arthro.2004.07.016\u003c/li\u003e\n\u003cli\u003eWilson TJ, Lubowitz JH (2013) Minimally invasive posterior hamstring harvest. Arthrosc Tech 2 (3):e299-301. doi:10.1016/j.eats.2013.04.008\u003c/li\u003e\n\u003cli\u003eLetartre R, Isida R, Pommepuy T, Miletic B (2014) Horizontal posterior hamstring harvest. Orthop Traumatol Surg Res 100 (8):959-961. doi:10.1016/j.otsr.2014.08.002\u003c/li\u003e\n\u003cli\u003eRoussignol X, Bertiaux S, Rahali S, Potage D, Duparc F, Dujardin F (2015) Minimally invasive posterior approach in the popliteal fossa for semitendinosus and gracilis tendon harvesting: an anatomic study. Orthop Traumatol Surg Res 101 (2):167-172. doi:10.1016/j.otsr.2014.12.009\u003c/li\u003e\n\u003cli\u003eThamrongskulsiri N, Limskul D, Tanpowpong T, Kuptniratsaikul S, Itthipanichpong T (2024) The Posteromedial Approach for Harvesting Hamstring Autografts Results in Fewer Incidents of Saphenous Nerve Injury Compared to the Conventional Anteromedial Approach: A Systematic Review and Meta-Analysis. Clin Orthop Surg 16 (4):559-569. doi:10.4055/cios23396\u003c/li\u003e\n\u003cli\u003eMochizuki T, Akita K, Muneta T, Sato T (2003) Anatomical bases for minimizing sensory disturbance after arthroscopically-assisted anterior cruciate ligament reconstruction using medial hamstring tendons. Surg Radiol Anat 25 (3-4):192-199. doi:10.1007/s00276-003-0130-1\u003c/li\u003e\n\u003cli\u003eSanders B, Rolf R, McClelland W, Xerogeanes J (2007) Prevalence of Saphenous Nerve Injury After Autogenous Hamstring Harvest: An Anatomic and Clinical Study of Sartorial Branch Injury. Arthroscopy: The Journal of Arthroscopic \u0026amp; Related Surgery 23 (9):956-963. doi:10.1016/j.arthro.2007.03.099\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Graft harvesting, Gracilis, posterior approach","lastPublishedDoi":"10.21203/rs.3.rs-7997508/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7997508/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eGraft harvesting is an important step when performing ligament reconstruction. The anterior approach is a well-described technique for hamstring tendon harvesting as it is commonly used for anterior cruciate ligament reconstruction, as an anterior incision is required to drill the tunnel. However, in case of gracilis harvesting for ankle ligament reconstruction, an anterior approach could lead to unnecessary complications and donor-site morbidity, and therefore the posterior approach is preferred, as it decreases complications and morbidity.\u003c/p\u003e\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eTo report donor site morbidity following gracilis harvesting using a posterior approach for anatomic ankle ligament reconstruction.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eBetween January 2023 and March 2025, 33 patients underwent anatomic ankle ligament reconstruction with a gracilis autograft for chronic ankle instability. In 2 patients, it was not possible to harvest the gracilis due to obesity, leaving 31 patients for assessment. The gracilis was harvested in flexion or extension position, based on the BMI of the patient. The authors noted graft length, diameter, time to harvest the gracilis, and whether patients had any neuropathy of the saphenous nerve or discomfort around the donor-site.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe remaining 31 patients comprised 12 males, and 19 females, were aged 36.8\u0026thinsp;\u0026plusmn;\u0026thinsp;12.6 (range, 17\u0026ndash;60) with a BMI of 27.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4 (range, 18\u0026ndash;37). Of the 31 patients, the gracilis was harvest with the knee flexed in 30 (97%), and knee extended in 1 (3%). The length of the graft was 18.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9 cm, and was cut to 13.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6 cm, with a diameter proximally of 3.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4mm and distally of 3.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5mm. The time to harvest the graft was 6.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3 minutes. At a follow-up of 5.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8 months, 1 patient reported neuropathy of the saphenous nerve, and 5 reported discomfort around the donor-site, which resolved in 3.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eGracilis harvesting using the posterior approach is a safe technique with minimal complications and donor-site morbidity.\u003c/p\u003e","manuscriptTitle":"Gracilis tendon harvesting using the posterior approach for anatomical ankle ligament reconstruction: a rapid and reliable technique with minimal neurological complications","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-23 09:17:45","doi":"10.21203/rs.3.rs-7997508/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"114d9624-2e39-4f46-9c1d-b387803aa228","owner":[],"postedDate":"April 23rd, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Rejected","date":"2026-05-03T07:30:21+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-03T07:40:10+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-23 09:17:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7997508","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7997508","identity":"rs-7997508","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}